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Commentary

Ambiguity and workarounds as contributors to medical error.

Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630.

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April 27, 2005
Spear SJ, Schmidhofer M. Ann Intern Med. 2005;142(8):627-630.

This commentary discusses the role organizations play in producing and contributing to medical errors. The authors contrast characteristics of error-prone organizations with high-performing ones and provide specific illustrations of how each type of organization designs and executes work, responds to problems, and reacts to the consequences. Examples from health care settings are included as well as discussion of case studies previously published in the Annals’ "Quality Grand Rounds" series. The authors suggest that health care organizations should not strive to become factories of repetition but, rather, should aim to define specific processes to foster an environment of continuous learning and improvement.

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Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630.